CSHBC ACPG 08 Infection Prevention Control Guidelines For AUD

INFECTION PREVENTION AND
CONTROL GUIDELINES FOR

AUDIOLOGY
March 2010
INTERORGANIZATIONAL GROUP FOR SPEECH-

LANGUAGE PATHOLOGY AND AUDIOLOGY
Disclaimer
While every effort has been made to ensure the accuracy of the contents of these guidelines, neither
the authors nor the Interorganizational Group for Speech-Language Pathology and Audiology accept
any liability, with respect to loss, damage, injury or expense arising from any errors or omission in
the contents of this work.
Interorganizational Group for Speech-Language Pathology and Audiology

The Canadian Interorganizational Group for Speech-Language Pathology and Audiology is
comprised of: the Canadian Alliance of Regulators of Speech-Language Pathologists and
Audiologists (CAR), the Canadian Association of Speech-Language Pathologists and Audiologists
(CASLPA) and the Canadian Academy of Audiology (CAA) representing the professional
associations, and the Canadian Council of University Programs (CCUP) in Communication Sciences
and Disorders. Their mandate is to coordinate the work of regulatory bodies, professional
associations and universities on projects/activities of mutual benefit and interest for the betterment of
the professions of speech-language pathology and audiology and to collaborate on the development
of practice standards and guidelines.
Update and Review

It is recommended that the contents of this document be reviewed and updated every three years, or
as required based on substantial changes in accepted infection prevention and control practice.
Changes to Web Links

Website addresses in this manual were accessed at the time of printing. Web addresses change
frequently and links may break. Linked sites are not under the control of the Interorganizational
Group for Speech-Language Pathology and Audiology. The Interorganizational Group is not
responsible for the contents of any linked site, including without limitation any link contained in a
linked site, or any changes or updates to a linked site.
Acknowledgements
The Interorganizational Group for Speech-Language Pathology and Audiology, Infection Prevention
and Control Guidelines Committee for Audiology would like to specifically acknowledge the work of
two groups: the Canadian Committee on Antibiotic Resistance (CCAR), Dr. A.U. Bankaitis and Dr. R.
Kemp, and the College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO) for
allowing the contents of their documents entitled Infection Prevention and Control Best Practices for
Long Term Care, Home and Community Care, Including Health Care Offices and Ambulatory
Clinics, Infection Control in the Audiology Clinic and Infection Control for Regulated Professionals,
respectively, to be reprinted with permission. A significant portion of the content and concepts of
these documents has been used in creating these audiology guidelines.
Prepared By
Members of the Infection Prevention and Control Guidelines Committee for Audiology have provided
clinical services in a variety of public and private practice settings with both paediatric and adult
populations. Individual committee members also have experience in academic teaching,
manufacturer representation, as well as administrative roles.
Patti-Jo Sullivan, M.Sc., AuD., R.Aud., F-AAA, Chair, Alberta
Jennifer Henley, AuD., R.Aud., Aud(C), Alberta
Marianne McCormick, M.Sc., AuD., Aud(C), British Columbia
Jillian Mills, M.Sc., AuD., Ontario
Ann Marie Newroth, M.Sc., British Columbia
Julie Purdy, Ph.D., Reg. CASLPO, Ontario
and in collaboration with the Speech-Language Pathology Infection Prevention and Control
Guidelines Committee
TABLE OF CONTENTS
INTRODUCTION............................................................................................................. 2
PURPOSE AND SCOPE ................................................................................................ 2
GUIDING PRINCIPLES .................................................................................................. 3
THE SCIENCE OF INFECTION CONTROL ................................................................... 4

The Immune System .................................................................................................. 4
Process of Infection................................................................................................... 4
PRECAUTIONS .............................................................................................................. 7
Standard Precautions or Routine Practices ............................................................ 7
Additional Precautions .............................................................................................. 8
STANDARD PRECAUTIONS OR ROUTINE PRACTICES ............................................ 8

Hand Hygiene ............................................................................................................. 8
Risk Assessment ....................................................................................................... 9
Risk Reduction Strategies....................................................................................... 10
Respiratory Etiquette .............................................................................................. 11
Client Accommodation............................................................................................ 11
Personal Protective Equipment .............................................................................. 11
Cleaning, Disinfection, and Sterilization................................................................ 15
Laundry..................................................................................................................... 18
Waste Handling ........................................................................................................ 19
Healthy Workplace Practices .................................................................................. 19
CONCLUSION .............................................................................................................. 23
APPENDIX A ................................................................................................................ 24
APPENDIX B ................................................................................................................ 25
GLOSSARY .................................................................................................................. 27
REFERENCES.............................................................................................................. 31
Infection Prevention and Control Guidelines for Audiology Page 1

INTRODUCTION
0BU
Infection prevention and control (IPC) in audiology practice refers to “the conscious
management of the clinical environment for purposes of minimizing or eliminating the
potential spread of disease.”1 IPC strategies are designed to protect clients, * health care F F
providers and the community. Research has shown that health care associated
infections cause significant morbidity and mortality, and at least 30% of health care
related infections can be prevented by following IPC strategies.2
Audiologists are responsible for ensuring the safety of the patients they serve. The
practice of audiology necessitates a high degree of patient contact, and both the patient
and the clinician are exposed to multiple environments that have been exposed to
numerous patients indirectly or directly (e.g., headphones, immittance tips, electrodes,
probe tubes, etc.), therefore, increasing the risk of exposure to infectious
microorganisms.3
Further, hearing health care services that are provided by an audiologist are sought by
a diverse population of patients differing across numerous factors such as age,
socioeconomic position, pre-existing disease, history of pharmaceutical interventions,
and other aspects that can influence the integrity of one’s immune system and their
ability to fend off potentially infectious microorganisms, subsequently resulting in a
heightened susceptibility for contracting an infection.(3) Furthermore, although cerumen
is not considered infectious unless contaminated with blood or mucous it should always
be treated as an infectious substance.1
Consequently, all audiologists and patients are possible carriers of infection, or at risk of
becoming infected. Each audiologist must be accountable and responsible for ensuring
IPC practices are used to maintain a safe and healthy hearing health care setting.
Audiologists play a critical role in the development and maintenance of IPC programs
whether they work on their own or as part of a multidisciplinary team.4
PURPOSE AND SCOPE

1BU
The purpose of these guidelines is to provide audiologists with succinct and practical
IPC information that is applicable across clinical practice settings. These may include
but are not limited to ambulatory and community clinics (including private practice
settings); childcare and school settings; long term care facilities (i.e., nursing homes,
homes for the aged, retirement homes, group homes); private homes; and hospital
settings (i.e., nursing units and intensive care units).
This document reviews standard † or routine precautions and additional precautions

F F
of relevance to the profession. Health Canada5 uses the term routine practices to
*
Client/Patient: refers to an individual receiving audiological care and will be used interchangeably throughout this document.
†
All glossary terms are identified in green bolding.

describe the system of IPC practices recommended in Canada to prevent and control
transmission of microorganisms. According to the World Health Organization (WHO),4
standard or routine precautions are to be applied to all clients at all times, regardless of
diagnosis or infectious status. Additional precautions, including airborne, droplet, and
contact precautions, may be necessary for certain situations when routine practices
alone are not sufficient to prevent transmission of disease.
This document is intended to guide clinical practice and decision-making on IPC issues.
Audiologists are encouraged to reflect on their individual practice and their typical
assessment and intervention procedures as they review the contents of these
guidelines. In some instances the documented recommendations will already be an
integral component of an audiologist's IPC practice, where in other instances, a change
or shift in clinical practice may be required in order to integrate use of the IPC
guidelines. Audiologists should also be aware of and comply with employer and/or
agency policies, occupational health and safety legislation, and any additional provincial
standards related to IPC, where they exist.
GUIDING PRINCIPLES
2BU
1. IPC strategies are designed to protect clients, audiologists, other service providers,
and the community.6
2. Health care associated infections can be prevented and/or minimized by following
IPC strategies.6
3. Audiologists follow IPC practices at all times and use critical thinking and problem
solving in managing clinical situations.6
4. A systematic approach to IPC requires each audiologist to play a vital role in
protecting everyone who utilizes the healthcare or education systems in all their
many forms.
5. Audiologists have an understanding of the following IPC core competencies required
to protect their patients and themselves in their work setting:7
 Understands basic microbiology and how infections can be transmitted in health
care settings
 Understands transmission based precautions
 Understands the activities of routine practices/standard precautions
 Understands the importance of hand hygiene/hand washing
 Knows, selects and demonstrates appropriate Personal Protective Equipment for
their jobs
 Appreciates the difference between clean, disinfected and sterile items
 Recognizes that reusable equipment that has been in direct contact with a
patient should be cleaned and reprocessed before use in the care of another
patient
 Demonstrates critical assessment skills related to exposure to infectious agents,
awareness to local outbreaks and use of infectious disease protocols
 Understands the role of vaccines in preventing certain infections

 Knows the infectious conditions that require absence from work or work
restrictions
3BU THE SCIENCE OF INFECTION CONTROL
The Immune System

11B
The immune system, the body’s defense system, is a complex network of specialized
cells, tissues and organs that has evolved to defend the body against attacks by
"foreign" invaders. When functioning properly the body fights off invasions from
microbes such as bacteria, viruses, fungi and parasites.8 Resistance to pathogenic
microorganisms can vary greatly from one individual to another. Some individuals may
be immune to infection or may be able to resist colonization by an infectious agent.
Other individuals exposed to the same microorganism may become asymptomatic
carriers. Still others will develop disease. Factors including, for example, age;
underlying diseases; and breaks in the “first line of defense” (e.g., factors such as
surgical operations, anesthesia, or invasive procedures) may make individuals more
susceptible to infection. Self care practices such as good hand hygiene, and respiratory
etiquette can all reduce the risk of infection.
Patients with compromised immune systems may lack the ability to fend off infections
from the aforementioned microbes that rarely cause disease or infection in healthy
individuals. Harmless microbes existing throughout the environment and under the right
conditions can cause serious, life-threatening illnesses in individuals with some level of
immunocompromise.1 Infections that take advantage of weakness in the immune
defenses are called “opportunistic infections”. From an IPC standpoint, it is crucial that
audiologists understand the concept of opportunistic infection, as many of the patients
the audiologist sees may be immunocompromised in some way.
Process of Infection
12B
For infection to occur, the microbe has to have a mode of transmission and a route of
transmission into a susceptible host. Mode of transmission of disease refers to the
means by which a potentially infectious agent is made accessible to a susceptible host.1
Natural orifices including the nose, eyes, and mouth are common entry points and
referred to as routes of transmission. Any break in the skin such as cuts, nicks, scrapes,
cracked hands are common routes for microbes to gain access to the susceptible host.
Once in the body, the microbe must be able to reproduce and resist the immune system
to produce disease.
Knowing the methods in which a disease is transmitted is important for implementing

proper infection control measures. Each disease has transmission characteristics based
on the nature of the microbe that causes it (see Table 1). The types of transmission are
not mutually exclusive. Some diseases can be transmitted in more than one way.
Adapted from Infection Control in the Audiology Clinic by Bankaitis and Kemp (2005).
Reprinted with permission from Auban Inc.

Table 1: Overview of infectious diseases and common microbes, microbial category
of the causative or microbial agent, and associated complications relative to the
hearing aid dispensing environment
Disease Microbial Complications
Category
AIDS virus (HIV) wide range of opportunistic infections causing malaise,
hearing disorders, systemic infection, death
Aspergillus fungus cutaneous infection
Candida fungus candidiasis, cutaneous disease of the skin and nails,
mucousal infection of the oral, esophageal, bronchial,
and/or vaginal surfaces, systemic infection, meningitis,
endocarditis, pulmonary infection
Chicken pox virus conjunctivitis, shingles, encephalitis
Coag neg bacterium folliculitis, furuncles, boils, carbuncles, bacteremia,
staphylococcus endocarditis, pneumonia, osteomyelitis
Common cold virus cough, occasional low-grade fever, malaise
Cytomegalovirus virus mild flu-like symptoms, moderate to severe
generalized infection, liver or spleen damage,
sensorineural hearing loss, visual impairment,
cognitive dysfunction
Hepatitis B (HBV) virus flu-like symptoms, jaundice, fever, liver damage,
death
Herpes simplex virus herpectic conjunctivitis, pain, discomfort, suppurative
inflammation of digits
Herpes zoster virus painful vesicular eruptions, discomfort
Influenza virus respiratory infection, fever, chills, headache,
myalgia, cough, sore throat
Otitis externa bacterium, itchy, dry ear canal skin, redness, edema, pain
fungus
Pseudomonas bacterium bacteremia, endocarditis, chronic otitis externa,
aeruginosa malignant otitis, otitis externa, pulmonary infections,
eye infections
SARS Prion (virus) fever, headache, body aches, discomfort, dry cough,
respiratory distress, death
Staphylococcus bacterium folliculitis, furuncles, boils, carbuncles, bacteremia,
aureus endocarditis, pneumonia, osteomyelitis
Streptococcal bacterium pneumonia, suppurative inflammation, endocarditis,
infection kidney problems
Tuberculosis bacterium persistent, dry cough, chronic lung infection, malaise,
weakness, loss of appetite, weight loss, fever, chills,
night sweats
The list in Table 1 is not exhaustive. As new infectious agents, such as the H1N1
influenza virus are identified health care practitioners must remain current with these
agents, their symptoms and the recommended infection control practices (Public Health
Agency of Canada, 2009).
There are four main modes of disease transmission: contact, vehicle, airborne, and
vector borne transmission.1
1. Contact Transmission: is the most frequent mode of disease transmission in
the healthcare setting. It involves the spreading of disease by way of touching or

coming in contact with potentially infectious objects. Contact transmission may
be direct, indirect or droplet.
a. Direct Contact Transmission: type of contact transmission which requires

close physical contact between an infected person and a susceptible person,
and the physical transfer of microorganisms. Direct contact includes touching
an infected individual, kissing, sexual contact, contact with oral secretions, or
contact with body lesions. Diseases spread exclusively by direct contact are
unable to survive for significant periods of time away from a host.9
b. Indirect Contact Transmission: refers to situations where a susceptible person

is infected from contact with a contaminated surface. Some organisms are
capable of surviving on a surface for an extended period of time. The microbe
has already been transferred from its original resting place to a secondary
surface. Frequent touch surfaces include door knobs, handrails, tables,
chairs, washroom surfaces, computers, office supplies and toys.9 Any touch
surface that cannot be easily cleaned and disinfected should be discouraged.
c. Droplet Contact Transmission: diseases can be transferred by infected

droplets contacting surfaces of the eye, nose, or mouth directly or indirectly.
Droplets containing microbes can be generated when an infected person
coughs, sneezes, or talks. Droplets are too large to be airborne for long
periods of time, and quickly settle out of the air.9 They are generally larger
than 5 microns and propelled short distances, less than one meter.10 Measles
and SARS are examples of diseases capable of droplet contact
transmission.9 Respiratory etiquette is an important consideration in order to
prevent the spread of droplet secretions.
2. Vehicle Transmission: occurs when disease is spread through ingestion of or

exposure to contaminated substances, via food, water, blood or body
substances. The ingestion of food contaminated with Salmonella, resulting in
food poisoning is one example of vehicle transmission. Another example is when
supplies of blood and blood products for transfusion services in many nations
were contaminated by HIV (human immunodeficiency virus) and hepatitis
viruses.9
3. Airborne Transmission: refers to situations where residue from evaporated

droplets or dust particles containing microbes can remain suspended in the air.9
This residue can remain suspended in the air for long periods of time and are
spread by air currents within a room or over a long distance. These organisms
must be capable of surviving long periods of time outside the body and must be
resistant to drying.9 Airborne transmission allows organisms to enter the upper
and lower respiratory tracts. Diseases that are capable of airborne transmission
include influenza, whooping cough, pneumonia, tuberculosis, measles and
chickenpox.9 While environmental controls (e.g., appropriate ventilation systems
and air handling) are especially important with regard to airborne transmission, a

hierarchy of controls is recommended. This hierarchy includes the use of
personal protective equipment.
4. Vectorborne Transmission: vectors are animals or insects that carry disease

and are capable of transmitting disease by interacting with a susceptible host.
Examples of vectors are flies, mites, fleas, and dogs.9 The most common vector
for disease is the mosquito for malaria, West Nile virus, and yellow fever and
through infected ticks for Lyme Disease.9, 11 Vectors are mobile and therefore
increase the transmission range of a disease.
4BU PRECAUTIONS
Standard Precautions or Routine Practices

13B
As mentioned previously, standard or routine precautions are to be applied to all clients

at all times, regardless of diagnosis or infectious status.4 They are the minimum practice
standard or activity that is expected.7
The elements classified as standard precautions/routine practices include:

 Hand hygiene
 Risk assessment related to client symptoms, care and service delivery, including
screening for infectious diseases, fever, respiratory symptoms, rash, diarrhea,
excretions and secretions
 Risk reduction strategies such as promoting use of respiratory etiquette, client
accommodation, and use of personal protective equipment, etc.
 Environmental cleaning, disinfection, and sterilization of multiple and single use
equipment and high touch surfaces
 Laundry and waste management
 Sharps injury prevention and post exposure management
 Healthy workplace practices including the education of audiologists, clients, their
families, and other staff regarding recommended immunizations and when to
stay home from work
The Canadian Committee on Antibiotic Resistance (CCAR)2 (http://www.ccar-

ccra.com/english/pdfs/IPC-BestPractices-June2007.pdf) offers fact sheets outlining
many of the standard or routine precautions listed above. These are available for public
use and may be reprinted without special permission (unless otherwise noted).
Standard or routine precautions are asterisked (*) to indicate the availability of a fact
sheet at the attached hyperlink. Appendix B of this document, Sample Audit Tool for
Implementation of IPC Practices (adapted from CCAR documents), also provides a
checklist of routine practices to be implemented by audiologists in their clinical
environments.

Additional Precautions
14B
Additional precautions may be necessary for certain situations when routine practices
are not sufficient to prevent transmission, such as patients with highly infectious
diseases or who are colonized with antibiotic resistant organisms (e.g., tuberculosis,
measles, MRSA). Additional precautions must be instituted as soon as indicated by
triggering mechanisms such as case history, diagnosis, symptoms of infection, and
laboratory information. There are three categories of additional precautions based on
mode of transmission: airborne, contact and droplet. It is recommended that health care
providers consult with an infection control practitioner within their health organization, or
their nearest Centre for Disease Control to determine when additional precautions are
required and how these should be implemented.
5BU STANDARD PRECAUTIONS OR ROUTINE PRACTICES
Hand Hygiene
15B
Hand hygiene* is the single most important way to prevent infection. Refer to the World
Health Organization (2009) document entitled WHO Guidelines on Hand Hygiene in
Health Care12 (http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf) for
a comprehensive review of this area.
Audiologists should perform hand hygiene:

 Before and after direct client care
 Between “dirty” and “clean” activities with the same client (e.g., immediately after
cerumen removal and before audiometry)
 Immediately after touching body fluids or any contaminated items in the
immediate environment
 Immediately after removing personal protective equipment such as gloves (e.g.,
after performing cerumen management)
 Prior to and after eating or smoking
 Prior to and after the application of cosmetics, lip balm or adjustments to contact
lenses
 After handling money or other items that may be contaminated
 After personal body functions, such as using the toilet or blowing one’s nose
 Immediately if skin is contaminated and/or injury occurs
 At the end of a workday
Audiologists should encourage clients to perform hand hygiene at the beginning of their
appointment, prior to handling any assessment and/or rehabilitation materials, or when
transitioning between "dirty" and "clean" activities.
Alcohol-based hand rubs are recommended to decontaminate hands in clinical

situations when hands are not visibly soiled. It is recommended that they contain a
minimum of 60% ethanol (ethyl alcohol).

Hand Rub Technique:
 Remove hand and arm jewellery
 Apply between 1 to 2 full pumps of product, or a loonie-sized amount onto one
palm.
 Spread product over all surfaces of hands, concentrating on finger tips, between
fingers, back of hands, and base of thumbs
 Rub hands until product is dry. This will take 15-20 seconds if an adequate
amount of product has been used. The entire hand rub technique process
should take approximately 20-30 seconds in total.
Hand washing must be performed when hands are visibly soiled. A disposable pump
dispenser is recommended in all settings except for individual client/resident personal
use, where bar soap is also considered acceptable. Antibacterial soaps may be used in
critical care areas such as Intensive Care Units (ICU) or in areas where invasive
procedures are performed.
Hand Washing Technique:

 Remove hand and arm jewellery
 Wet hands with warm water (hot water will lead to dryness)
 Apply soap
 Vigorously rub all aspects of your hands for a minimum of 15 seconds, paying
particular attention to finger tips, between fingers, backs of hands and base of
thumbs
 Rinse and dry hands thoroughly by blotting gently so as not to damage the skin
 Turn off taps with paper towel, if available
Soaps, antimicrobial agents, and extra hand washing can be hard on the hands. To
maintain skin integrity it is important to use hand lotion.
Risk Assessment
16B
Risk assessment* is the process of systematically evaluating risks to safety and

health.13 A risk assessment procedure includes the following:
Step one: Identifying hazards and those at risk:

 From a specific interaction (e.g., face-to-face interaction with a client,
transport of a client, etc.)
 With a specific client (e.g., infants, clients with respiratory illness, etc.)
 In a specific environment (e.g., classroom, private home, therapy
room, etc.)
Step two: Evaluating and prioritizing risks:

 Estimate the risks regarding severity and probability of causing harm
Step three: Deciding on preventive action to eliminate or control the risks
Step four: Taking action to put preventive and protective measures in place

Step five: Monitoring and reviewing
The same process would apply to decision-making regardless of the practice setting.
Audiologists should be prepared to ask a few simple questions in the clinic setting to
confirm whether or not assessment and/or aural rehabilitation should proceed, and/or
whether standard and/or additional precautions are required. Questions regarding
communicable diseases (such as coughs, fevers, rashes, diarrhea, and eye infections)
should be included as part of the screening. Questions regarding recent exposures to
infectious disease such as chickenpox or tuberculosis and recent travel, depending on
what is prevalent in the community, should also be asked.
Remember all body fluids are considered as possibly infectious. Body fluids include
blood, drainage from scrapes and cuts, feces, urine, vomit, nasal discharge, and saliva.
Cerumen is not considered infectious unless contaminated with blood or mucous. The
colour and viscosity of cerumen, however, makes it difficult to detect the presence of
such bodily fluids, particularly if the material is clear like mucous or dark-coloured like
dried blood. Due to the potential for contamination, cerumen should always be treated
as an infectious substance.1
Information regarding when to stay at home or cancel an appointment should be

provided to prospective clients at the time of initial booking. A script could include the
following:
If you/your child have symptoms of fever and cough, diarrhea, rash, or
untreated eye infections within 24 hours of your appointment, please let
this office know before the scheduled appointment. Visits can be re-
scheduled due to illness.
A sample screening poster and screening questionnaire for febrile respiratory illness are
available on pages 29-30 of The Canadian Committee on Antibiotic Resistance (CCAR)
(2007) document (http://www.ccar-ccra.com/english/pdfs/IPC-BestPractices-
June2007.pdf).
Audiologists should also be aware of health and travel alerts regarding exposure to
infectious diseases including pandemics. They would be advised to follow the guidelines
put forth by the Ministry(ies) of Health related to specific situations.
Risk Reduction Strategies

17B
Risk reduction strategies must be implemented once the risk assessment has been
completed. Strategies such as hand hygiene, respiratory etiquette, accommodation, use
of personal protective equipment (PPE), cleaning and disinfection or sterilization of
equipment are all considered risk reduction strategies as their implementation will
reduce the risk of infection transmission.

Respiratory Etiquette
22B
Respiratory etiquette* involves measures to contain respiratory secretions for all

individuals with signs and symptoms of a respiratory infection. They include the
following:
 Cover nose/mouth when coughing or sneezing – cough into elbow or sleeve.
Never use your hand!
 Use tissues to contain respiratory secretions and dispose of them in nearest
waste receptacle after use.
 Perform hand hygiene (e.g., hand washing or use alcohol-based hand rub) after
having contact with respiratory secretions and contaminated objects.
Patients should be prompted to self-assess when booking appointments and should be

educated about respiratory etiquette.
A sample respiratory etiquette poster is available on page 31 of the The Canadian

Committee on Antibiotic Resistance (CCAR) (2007) document2 (http://www.ccar-
ccra.com/english/pdfs/IPC-BestPractices-June2007.pdf).
Client Accommodation
23B
In acute and residential care settings, patients should be assigned to single rooms if
they are likely to contaminate the environment and transmit infection. In outpatient
settings, patients may be seated in a separate waiting room while they await their
appointment or rescheduled if they are likely to contaminate the environment and
transmit infection.
Maintaining a 1 to 2 metre distance from a client is recommended until an initial

screening can be completed. Sitting beside the client rather than across from them is
preferred.
Personal Protective Equipment

24B
Barriers or personal protective equipment PPE* are required whenever there is a risk of
coming in contact with non-intact skin, mucous membranes or body fluids. PPE may
serve to protect the audiologist and/or may serve to protect the client when the
audiologist presents with non-intact skin, or a respiratory virus or infection.
For audiologists, common situations that may require the use of PPE would include:
 if ear drainage, blood, sores or lesions (on the scalp) are evident
 when the audiologist's skin or client’s skin is broken
 handling of earmolds or hearing aids directly from patients
 the removal or handling of earmold impressions
 performance of cerumen management
 cleaning or disinfecting instruments contaminated with cerumen
 any audiological services provided in environments where additional precautions
have been identified (i.e., a client with C-difficile in a hospital setting, additional
airborne or droplet precautions in a long term care facility, etc.)
 handling dirty laundry or waste materials

 cleaning up spills of body fluids or when disinfecting a contaminated area
 when dealing with immunocompromised clients
Gloves are the most commonly worn PPE. They do not replace good hand hygiene;
however, they should be worn when there is a risk of coming in contact with non-intact
skin, mucous membranes, or body fluids. Gloves are not required for routine care
activities in which contact is limited to intact skin. Gloves are available in a variety of
sizes and should fit tightly to one’s skin to prevent any interference when performing
audiological procedures. Glove material should be chosen based on the risks for which
they are being worn (e.g., vinyl for personal care, latex for sterile invasive procedures,
nitrile for exposure to chemicals). Single use disposable gloves must not be reused or
washed. Gloves should be located in the labs, sound suite, hearing aid fitting rooms and
available in different sizes.
Remove or change gloves and perform hand hygiene when:

 moving between dirty and clean procedures, even on the same client (e.g.,
following cerumen management and moving on with audiometry)
 after contact with contaminated items
Gloves should be removed immediately after completion of the procedure at point of

use and before touching clean environmental surfaces.
Proper procedure for removal of gloves is as follows:

 With both hands gloved, grasp the outside of one glove at the top of your wrist.
 Peel off this first glove, peeling away from your body and from wrist to fingertips,
turning the glove inside out.
 Hold the glove you just removed in your gloved hand.
 With your ungloved hand, peel off the second glove by inserting your fingers
inside the glove at the top of your wrist.
 Turn the second glove inside out while tilting it away from your body, leaving the
first glove inside the second.
 Dispose of the entire bundle promptly in a waterproof garbage bag. Do not
reuse!
 Wash your hands thoroughly as soon as possible after removing gloves and
before touching any objects and surfaces.
Adapted from: Occupational Health & Safety Agency for Healthcare in BC (OHSAH)
(2008) Home and Community Care Risk Assessment Tool: Resource Guide14
(http://www.ohsah.bc.ca/552/3415/)
Masks, eye protectors, and face shields are used to protect the audiologist’s nose,
mouth, and eyes from splashes and/or sprays of potentially infectious materials, or
when the audiologist or client is at risk of airborne contamination.12 Likewise, they can
be used to protect a client. The use of this protective apparel would be considered
droplet precautions, as the microbe carrying droplets can land on mucous membranes
of the mouth and nose or contaminate the conjunctiva of the eyes, all of which are

portals for infection. Splashes and sprays can occur when a client is coughing or
sneezing or during procedures such as using a buffing or grinding wheel.
Fit-tested masks (e.g., N95 masks) are used when airborne precautions are indicated.
The audiologist must be ‘fit tested’ in order to ensure that the mask fits tightly to the face
and filters airborne organisms. A fit-tested mask is worn when:
 the client has a known or suspected airborne infection (e.g., tuberculosis,
chickenpox, measles, hantavirus)
 performing aerosolizing procedures with a client with droplet infection (e.g., open
suctioning)
 there is a health alert that requires use of a fit-tested mask
Masks and eye protection should be worn within 1 to 2 metres of the coughing or
sneezing client in order to prevent the transmission of microorganisms. Eyes should be
covered from all directions.
Gowns are recommended to be worn anytime the chance of contamination to clothing

exists. Gowns should be discarded immediately after completion of the procedure at the
point of use. One example of when an audiologist should don a gown would be during
vestibular assessments to protect the audiologist in case the patient becomes ill.
The proper sequence for donning PPE is as follows:

1. gown
2. mask
3. eye protection
4. gloves
The proper sequence for removal of PPE is as follows:

1. gloves
2. gown
3. wash hands prior to removing the mask
4. mask
Refer to page 37 of The Canadian Committee on Antibiotic Resistance (CCAR) (2007)2

document fact sheet entitled The use of gowns, aprons, and lab coats for further
information (http://www.ccar-ccra.com/english/pdfs/IPC-BestPractices-June2007.pdf).
Table 1 from the CASLPO (2006) Infection control for regulated professionals15
document
(http://www.caslpo.com/Portals/0/positionstatements/InfectionControlCASLPOEDITION.
pdf) is re-produced, with adaptations, below. It provides a comprehensive summary of
risk assessment and risk reduction strategies for different situations.

Table 2: Assessing the Risk**
Situation Infection Control Strategy
(escalating from least to most invasive)
Routine Client Care Routine Precautions
No physical contact  Hand washing
Communication with client >1 metre  Respiratory etiquette (cover mouth nose when
away coughing or sneezing, followed by proper hand
washing)
Physical Contact with client intact skin Contact Precautions
 Hand washing
Physical contact with client, you or
U Contact Precautions
client has infected or open wound,
U  Hand washing
non-intact skin, no respiratory  Gloves
concerns  Proper removal and disposal of gloves followed by
hand washing
Contact with client, procedure may Droplet Precautions
involve body fluids, splashing  Hand washing
(droplets)  Use professional judgment:
Gloves
Surgical Mask
Eye protectors
Gowns
 Proper removal and disposal of PPE followed by
hand washing
Close contact with client, respiratory Droplet Precautions
symptoms  Hand washing
 Respiratory etiquette
 Use professional judgment:
Gloves
Surgical mask for you and/or your client
Eye protectors
Close contact with client, fever and Droplet Precautions
respiratory symptoms  Hand washing
 Respiratory etiquette
 Use professional judgment:
Gloves
Surgical mask for you and/or your client
Eye protectors
 Follow health alerts if applicable
Contact with client with known Airborne Precautions
airborne infection e.g., active TB  Droplet Precautions with fit-tested mask
 Proper ventilation
Health Alert in effect Follow Ministry of Health Directives
**In audiology, the practice environment may dictate the infection control strategy used
in a given situation. For example, close contact with a client who has fever and/or
respiratory symptoms in an acute care setting may necessitate the use of PPE. In a
school or community clinic environment, PPE may be less accessible. Standard practice
in these types of environments would involve re-scheduling of a client appointment until
such a time as symptoms have disappeared.

Cleaning, Disinfection, and Sterilization
18B
1. Clinical Equipment
Equipment that is reused must be reprocessed by cleaning, disinfection and/or
sterilization after each patient to prevent transmission of disease and to maintain the
integrity of the equipment. It is beyond the scope of this document to describe all the
components of a full equipment reprocessing protocol that meets best practice
standards. PIDAC (2006) Best Practices for Cleaning, Disinfection and Sterilization in
H
All Health Care Settings 16 is a comprehensive and current guide related to the areas of
H
cleaning, disinfection and sterilization. Clinicians who are responsible for the
development of reprocessing protocols are strongly encouraged to consult this
document for further information.
1.1 Levels of Reprocessing:

Cleaning: the physical removal of foreign material (e.g., dust, soil, organic material
such as blood, secretions, excretions and microorganisms). Cleaning physically
removes rather than kills microorganisms. It is accomplished with water, detergents and
mechanical action. Thorough and meticulous cleaning is required before any
equipment/device may be decontaminated, disinfected and/or sterilized.
Disinfection: refers to the inactivation of disease-producing microorganisms17 and

reduction in the number of viable microorganisms.18 The level of disinfection depends
on the extent to which microbes are eliminated.19 Disinfection does not destroy all
bacterial spores.17 Disinfectants are used on inanimate objects in contrast to antiseptics,
which are used on living tissue.
High Level Disinfection (HLD): The level of disinfection required when processing
semicritical medical equipment/devices. High level disinfection processes destroy
vegetative bacteria, mycobacteria, fungi and enveloped (lipid) and non-enveloped (non-
lipid) viruses, but not necessarily bacterial spores. Medical equipment/devices must be
thoroughly cleaned prior to high level disinfection.
Low Level Disinfection (LLD): Level of disinfection required when processing

noncritical medical equipment/devices or some environmental surfaces. Low level
disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid)
viruses. Low level disinfectants do not kill mycobacteria or bacterial spores. Medical
equipment/devices must be thoroughly cleaned prior to low level disinfection.
Sterilization: The level of reprocessing required when processing critical medical

equipment/devices. Sterilization results in the destruction of all forms of microbial life
including bacteria, viruses, spores and fungi. Equipment/devices must be cleaned
thoroughly before effective sterilization can take place.
The Spaulding Classification is used to determine the proper level of reprocessing for
clinical equipment. The Spaulding Classification defines three categories of equipment:

critical, semi-critical and non-critical and specifies the corresponding levels of
reprocessing required for each.
Table 3: The Spaulding Classification

Category Level of Examples
Processing/Reprocessing
Critical
 Items that enter sterile tissue, Cleaning followed by  Generally not applicable to
including the vascular system. Sterilization audiology practice.
Semi Critical
 Items that come in contact with Sterilization or Any item entering the ear
non-intact skin or mucous Disposable/Single Use is canal: Insert earphone,
membranes but do not preferred. impedance probe tips, curettes
penetrate them. Cleaning followed by High and other cerumen equipment,
 Items that contact cerumen are Level Disinfection (HLD) as a otoscope tips, probe tubes.
considered semi-critical due to minimum.
potential contamination with
blood and body fluids.
Non-critical Insert earphones (exclusive of
 Items that contact only intact Cleaning followed by Low foam tip), Bone conduction
skin or do not directly touch the Level Disinfection (LLD) oscillator, Patient response
client. button, Listening Stethoscope
1.3 Semi-critical Equipment

All reusable audiological equipment that is classified as semi-critical must be
reprocessed by thorough pre-cleaning followed by either sterilization or high-level
disinfection as a minimum. The preferred sterilization technique is heat under pressure
in an autoclave. Unfortunately, most implements used by audiologists would melt under
these conditions.19 Chemical solutions containing hydrogen peroxide or glutaraldehyde,
often referred to as cold sterilants, are also available to achieve either sterilization or
high-level disinfection. Effective sterilization and/or high level disinfection using these
chemical solutions is dependent on many factors including:18
 The use of solutions classified for sterilization and/or high-level disinfection only.
Products classified as intermediate or low-level disinfectants are not adequate.
 The physical properties of items being sterilized. Items must be relatively smooth,
impervious to moisture, and be of a shape that permits all surfaces to be
exposed to the solution.
 Adequate exposure to all surfaces, both interior and exterior. Tubing must be
completely filled and the items must be clean and arranged in the solution to
assure total immersion. The items must be completely submersed in the solution
for the prescribed period of time.
 Use of efficient solutions. The solution must be clean and fresh. Most products
come in solutions consisting of two parts that when added together form what is
referred to as an "activated" solution. The shelf life of activated solutions is
indicated in the instructions for commercial products. Generally, this is from one
to four weeks.
 Rinsing. Instruments, implants, and tubing (both inside and out) should be rinsed
with sterile saline or sterile water prior to use to avoid tissue damage.

 Integrity of reprocessing. Items must be packaged, transported and stored after
reprocessing in such a way to maintain integrity until point of use.
It is strongly recommended that sterilization and/or high level disinfection be performed

in a centralized area that complies with all necessary physical and human resource
requirements. It is unlikely that either sterilization or high-level disinfection can be
adequately achieved in a typical clinical setting. Furthermore, due to potential toxicity of
cold sterilants, these solutions must be handled carefully by properly trained staff in a
well-ventilated setting using appropriate personal protective equipment. Single-usage
semi-critical equipment is therefore recommended as an alternative to reusable
equipment whenever possible and especially in cases where a centralized reprocessing
service is not available.
Audiological supplies should be labelled by the manufacturer or supplier as single use

or re-usable. Those items labelled as single-usage should not be reprocessed. Single
use items are for use with a single client only and may only be reused on that same
client within a short duration of time (e.g., during the same appointment). Single use
items should not be reused with the same client if there is visible discharge on them.
Available single use items include:
 Probe microphone tubes
 Plastic otoscope specula
 Plastic earmold impression syringe tips
 Insert earphone foam tips
 Single-use OAE probe tips
 Disposable ABR electrodes
 Otoblocks
The decision whether to reprocess semi-critical equipment or to use only single-use

items involves risk management and cost considerations that may vary across practice
settings. Therefore clinicians must carefully consider these factors when developing
their site-specific reprocessing standards for semi-critical equipment.
1.4 Non-Critical Equipment

Any items or surfaces that contact only intact skin or do not directly touch patient skin
are considered non-critical and can be reprocessed through cleaning followed by low-
level disinfection. Low level disinfectants include quaternary ammonium compounds,
3% hydrogen peroxide, and diluted bleach (1:1000). BC CDC Laboratory Services: A
Guide to Selection and Use of Disinfectants, 2003
(http://www.bccdc.ca/NR/rdonlyres/EAA94ACF-02A9-4CF0-BE47-
3F5817A25669/0/InfectionControl_GF_DisinfectntSelectnGuidelines_nov0503.pdf)
provides further information about chemical solutions that can be used to achieve low
level disinfection.
Non-critical audiological equipment that is used in direct patient care should be cleaned
and disinfected between clients. This includes items such as otoscopes (excluding
disposable tips), supra-aural earphone cuffs and headbands, bone conduction

oscillators and patient response buttons. Note that some low level disinfectants must
remain wet for a period of three to five minutes for full action so this time must elapse
before the next patient use.
2. Clinical Environment
A regular cleaning and disinfection schedule should be developed for general
environmental surfaces such as countertops, floors, telephones and computer
keyboards. A cleaning and disinfection checklist for audiologists, adapted from CASLPO
(2006), is outlined below.15
Table 4: Cleaning and Disinfection Check List for Environmental

Surfaces/General Housekeeping
Practice What to Use Recommendations
Considerations
 Floors *Cleaning usually involves soap and  Daily and when visibly soiled
 Sinks water, detergents or enzymatic  Clean high traffic areas more
 Desks or agents to physically remove soil, dust frequently (e.g., reception counter,
countertops or foreign material. chair in sound suite)
 Storage shelves and *Low Level Disinfection: Quartenary  Keep shelves and bins tidy and
bins Ammonium Compounds, or clean, dust free
 Telephones, Iodophores, or 3% Hydrogen  Following use or prior to use if
computers, credit Peroxide, or Diluted Bleach (5mls suspected contamination
card reader bleach/500 mls water).  Care must be taken to ensure
 Washrooms (public Plush toys and reading materials residues from the cleaning process
and staff) (e.g. magazines, books) which are itself (e.g., detergents, solvents,
 Fitting/repair rooms handled and cannot be laundered, etc.) are also removed from
 Sound suites should be discarded. equipment.
 Toys used for  Consider laminating paper material
assessment used by patient/clients repeatedly
during intervention so that it can be
wiped with disinfectant.)
Laundry
19B
The risk of actual disease transmission from soiled linen is negligible provided that
hygienic handling, storage and processing of clean and soiled linen occurs.2
Collection and handling of linen should be completed with a minimum of agitation and
shaking. Soiled linen should be placed in a laundry basket or waterproof bag (not on the
floor). In home and office settings, any laundry* soiled with blood or body fluids should
be handled while wearing gloves. Touching soiled linen to one’s clothes or skin should
be avoided. Heavily soiled linen should be rolled or folded to contain the heaviest soil in
the centre of the bundle.
Laundry carts or hampers do not need to be covered from an infection prevention

perspective however they should be cleaned after each use. If a cloth laundry bag is
used to store or transport soiled linen, it can be washed in the same cycle as the linen
contained within it.
It is impossible to clean laundry when organic material is present. Solid soil, feces or
blood clots should be removed from linen with a gloved hand. Linens may then be

laundered together using detergent and dried in a hot air dryer to ensure killing of
microorganisms. Cold water wash may be used if cold water detergent is available.
Complete wash and rinse cycles should be used. In a home setting, machine drying or
hanging clothing and linens on a clothes line are both suitable methods for drying.
Clean laundry must be stored separately from soiled linens.
If clothing containing blood or body fluids is sent to a community dry cleaner, it should
be appropriately labelled.
Waste Handling
20B
Waste handling is divided into three categories: general, biomedical, and pathological.
Legislation requires that biomedical waste, including sharps such as needles and
blades, be handled and disposed of in a manner that prevents transmission of potential
infections. Local, regional, provincial and federal regulations on waste segregation must
be followed.
Waste that is contaminated with blood, ear drainage or cerumen containing blood or ear
drainage, can be placed in the regular waste receptacles. However, it should be
separated from the rest of the trash to avoid casual contact. Place this waste in small
plastic bags or wrap in paper before disposing in trash.
General office waste, used gloves or non-sharp medical equipment may be disposed of
in regular waste receptacles. It is recommended that waste be packaged in a leak-proof
container that can be disposed of (e.g., plastic bag) or cleaned after emptying (e.g.,
plastic waste bin or trash can). Waste should be emptied frequently and stored in a
manner that protects it prior to pick up/disposal.
Special consideration must be given to spills of blood and body substances. Routine
precautions must be implemented (gloves, masks, eye protection). The spill area must
initially be cleaned using disposable towels. The clean area then requires disinfection
with a low level disinfectant. Rinse and dry the area using disposable towels. All waste
must be disposed of in a plastic lined container. Once waste is disposed of, perform
hand hygiene immediately.11
Any sharps in the practice setting should be disposed of immediately in a clearly

labelled, puncture resistant container. The container should have a tightly fitting lid that
seals and prevents leakage.
Healthy Workplace Practices

21B
Adapted from The Canadian Committee on Antibiotic Resistance (CCAR) (2007)2

(http://www.ccar-ccra.com/english/pdfs/IPC-BestPractices-June2007.pdf)
Healthy workplace practices involve several factors:

Immunizations: Audiologists are at risk for exposure to and transmission of a variety of
U U
vaccine preventable diseases, because of their contact with patients. Use of immunizing
agents protects both the audiologist and patients from being infected. Any practice
setting that provides direct patient care should ensure that all audiologists providing
patient care have the opportunity to access appropriate vaccinations. Considerations
related to immunization for audiologists should include an awareness of one’s own
history of childhood communicable diseases. Another consideration, as per employer
policies, is that any new staff should have a tuberculin skin test at the beginning of their
employment, unless they have documentation of a negative skin test in the past 12
months.
Recommended immunizations for all healthcare workers, including audiologists, are:

 Annual influenza immunization
 Measles, mumps and rubella (MMR), two doses
 Diphtheria, polio and tetanus (DPT)
 Hepatitis B
 Varicella vaccine (chickenpox) – recommended for anyone who may be
susceptible (history for disease is negative, IgG negative)
 Meningococcal (If working directly with patients with disease)
Staying home from work: Knowing when to stay home from work is another important
U U
consideration in IPC. In the event of a health alert, audiologists should follow Ministry of
Health Guidelines or other relevant guidelines.
Audiologists are encouraged to stay home from work under the following conditions:
 Febrile respiratory illness
 Dermatitis on their hands (consult your physician about your risk)
 Cold sores or shingles that cannot be covered
 During the initial days of a respiratory illness
 Diarrhea
 Eye infections until treated
Most employers will have policies that should be adhered to in this regard. The same
recommendations would also apply to clients, who should be encouraged to re-
schedule their visit under any of the above conditions (refer to Risk Assessment section
of this document).
Education : Audiologists should demonstrate knowledge and work practices that reduce
U U
the risk of infection. Healthy workplace practices involve providing leadership and acting
as a role model to other service providers, clients, and families related to IPC. Appendix
A provides an outline of the Core Competencies in Infection Prevention and Control for
All Health Care Providers. These competencies cluster around the following areas:
critical assessment skills, understanding the basic rationale for routine practices,
personal safety, use of routine practices, cleaning, disinfection, sterilization, waste
management, and additional precautions.

Employees and staff audiologists as part of their new-hire orientation should receive
infection control training. It is imperative that all employees be made aware of the
organization’s infection control practices, including location of IPC manual, materials
and methods/safety practices of disinfecting/sterilizing equipment. Further, yearly
updates on the area of infectious disease and infection control are required to ensure
that practice standards reflect changes in the workplace.
Post Exposure Management. Audiologists should ensure they are familiar with
U U
employer procedures related to punctures or mucous membrane exposures to blood

borne pathogens or other potentially infectious agents. Employer guidelines should be
consulted following an exposure to any potentially infectious agent but should guidelines
not be available in a given work setting, the following are designed to outline
appropriate steps to minimize the seriousness of exposure. While the following are the
most common infectious agents encountered in an audiological practice, others might
be causes of potential harm (for example, avian flu) with further information available on
the Health Canada website at www.hc-sc.gc.ca.
1. Hepatitis B [HBV]/Hepatitis C [HBC]/Human Immunodeficiency Virus [HIV]:

While the risk of exposure to blood borne pathogens via body fluids is minimal in
the field of audiology, risk is possible during procedures such as the taking of ear
mold impressions and the removing of cerumen. In spite of using precautions
such as the use of gloves, it is possible that the audiologist might come in contact
with blood products. In order to address post exposure management methods, it
is important to differentiate between whether the exposure occurred superficially
(on intact skin) and whether the contact penetrated the skin via an injury or non-
intact skin exposure. If the contact occurred only superficially, no action is
required; however, if the contact occurred with non-intact skin, the following is
recommended:
a. HBV: If the audiologist is not already immunized against HBV, it is
recommended that they receive a hepatitis B vaccination series as soon as
possible, preferably within 24 hours after the incident and no more than 7
days following the incident.
b. HCV: Consider testing as a baseline within 7-14 days of the incident and
again as a follow-up 4-6 months following the incident.
c. HIV: Unless the patient with whom the incident occurred is known to be
infected or is considered high risk, generally no action is required.
Should the exposure be deemed invasive rather than either superficial exposure
or non-intact skin, it is recommended that the audiologist consult the Public
Health Agency of Canada, their occupational health department or their physician
IMMEDIATELY for the most current post management options.
2. Tuberculosis [TB]: Following treatment in close proximity to a patient with

known TB, compliance to hospital or provincial guidelines should be following
which will typically include a tuberculin skin test with treatment should the
audiologist test positive for mycobacterium tuberculosis (TB).

3. Influenza: While annual vaccinations against influenza are recommended for all
audiologists working directly with patients, it is possible (and highly likely) that
atypical influenza outbreaks will require additional management strategies.
Audiologists should consult with their provincial Centre for Disease Control for
specific instructions during atypical outbreaks.
4. Meningococcal Disease: Should intensive, unprotected contact (i.e., without

wearing a mask) occur, the audiologist should receive antimicrobial prophylaxis
following exposure.

CONCLUSION
6BU
The purpose and scope of these guidelines is to provide audiologists with succinct,
practical IPC information that is applicable across a variety of practice settings.
Audiologists are encouraged to familiarize themselves with the Core Competencies for
Infection Prevention and Control for Health Care Providers (Appendix A), to reflect on
their own IPC knowledge in relation to these competencies, and to consider their own
individual practice as they review the contents of these guidelines. A sample audit form
for Implementation of IPC Practices (Appendix B) has been made available to assist
with the practical implementation of these recommendations. It is our intent that the
implementation of these guidelines while developing audiology specific work practice
controls will ensure safe practice environments related to IPC for both audiologists and
the clients whom we serve.

APPENDIX A
7BU
Core Competencies for Infection Prevention and Control for Health Care Providers
Source: Community and Hospital Infection Control Association (2006)
Target Audience: Individuals who are accountable for the quality of health care delivered in
Canada.
AREA OF COMPETENCY DETAILED CORE COMPETENCY

Critical Assessment Skills  Critical assessment skills related to exposure
These skills are the under-pinning for the other five to infectious agents, awareness to local
core competencies outbreaks and use of infectious disease
specific protocols
Basic Rationale for Routine Practices  Understands basic microbiology and how
infections can be transmitted in health care
settings
Personal Safety  Knows how to appropriately manage sharps,
blood and body fluids and recognizes the
appropriate first aid activities for exposures to
blood and body fluids
 Understands the role of vaccines in preventing
certain infections, including annual influenza
immunizations for health care workers
Routine Practices  Understands the importance of hand
hygiene/hand washing
 Understands the activities of Routine
Practices/Standard Precautions
 Respiratory Etiquette
 Knows and selects appropriate Personal
Protective Equipment (PPE) for their job(s)
 Demonstrates appropriate use of PPE
Cleaning, Disinfection, Sterilization, Waste  Maintains safe clean environment
Management  Understands importance of using PPE when
sorting laundry
 Recognizes that re-usable equipment that has
been in direct contact with a client should be
cleaned and reprocessed before use in the
care of another client
 Appreciates the differences between clean,
disinfected (low, medium, and high-level) and
sterile items
 Knows the difference between regular and
biohazard wastes
Additional Precautions  Understands Transmission Based Precautions
(Additional Precautions): Why and when they
are used

APPENDIX B
8BU
(Adapted from Appendix III – Audit Tool, Canadian Committee on Antibiotic Resistance (CCAR) Infection Prevention and Control Best
Practices for Long Term Care and Community Care Including Health Care Offices and Ambulatory Clinics)
Checklist or Audit Tool for Implementation of IPC Practices (i.e., applicable to public and private audiology practice settings)
Date Checklist / Audit completed:

By:
Items Comments
Implemented
Implemented
Implemented
Partially
Fully
N/A
Not
WAITING AREA
Infection control signs at entry
Infection control signs at reception desk
Alcohol-based hand cleaner and signage
Tissue boxes available
Garbage cans available
Clean toy and soiled toy bins available (or if no toys or
magazines available, a sign indicating rationale)
RECEPTION
Personal Protective Equipment (PPE) available
(masks, gloves)
Reception staff can maintain 1 metre distance from
patients
Telephone screening protocol has been developed
and implemented
TREATMENT ROOMS
Alcohol-based hand cleaner available in all rooms OR

Items Comments
Implemented
Implemented
Implemented
Partially
Fully
N/A
Not
Hand washing sinks with soap available in all rooms
Rooms only have essential supplies
Written policies exist for decontaminating treatment
rooms between patients and at the end of the day
CLEANING PROCEDURES
Written procedures for cleaning the office setting have
been provided by (or to) the cleaning staff
Approved and appropriate disinfectant products are
available for patient surfaces
Approved and appropriate disinfectant procedures are
available for equipment and instruments
PROTOCOL DEVELOPMENT AND STAFF TRAINING
Annual staff training or updating completed on
infection prevention
Annual staff training on proper PPE use
DISINFECTION / STERILIZATION OF MEDICAL DEVICES
Manufacturer’s instructions are followed
Process for cleaning semi-critical and critical devices
including written protocols for:
disassembly
sorting and soaking
physical removal of organic material
rinsing
drying
physical inspection
wrapping

GLOSSARY
9BU
Additional precautions: Interventions implemented for certain pathogens or clinical

presentations in addition to routine infection control practices, to reduce the risk of
transmission of microorganisms from patient to patient, patient to health care worker,
and health care worker to patient.16 http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/02pdf/28s1e.pdf
Airborne precautions: These are additional to standard precautions and are designed
to reduce the transmission of diseases spread by the airborne route.15
Airborne transmission: A manner of spreading diseases through microbial exposure

suspended in the air as droplet residue or dust particles.1
Bacteria: Life-form consisting of a single DNA molecule suspended in cytoplasm and

encased within a thin cell wall that is capable of independently executing all the
functions and processes necessary for survival and potentially capable of causing
disease.1
Cleaning: The physical removal of foreign material (e.g., dust, soil, organic material
such as blood, secretions, excretions and microorganisms). Cleaning physically
removes rather than kills microorganisms. It is accomplished with water, detergents and
mechanical action. Thorough and meticulous cleaning is required before any
equipment/device may be decontaminated, disinfected and/or sterilized.16
Clinical Practice Setting: These may include but are not limited to ambulatory and
community clinics (including private practice settings); childcare and school settings;
long term care facilities (i.e., nursing homes, homes for the aged, retirement homes,
group homes); private homes; and hospital settings (i.e., patient care units or services).
Colonization: The presence of microorganisms in or on a host with growth and

multiplication but without tissue invasion or cellular injury.12
Contact precautions: These are additional to standard precautions and are designed
to reduce the risk of transmission of microorganisms by direct or indirect contact.15
Contact transmission: A manner of spreading disease through microorganisms that

are transmitted by touching or coming in contact with potentially infectious objects. The
spread of disease may occur either via direct, indirect, or droplet contact.1
Critical equipment: A medical device that enters sterile tissues, including the vascular
system. Critical medical devices present a high risk of infection if the device is
contaminated with any microorganisms, including bacterial spores. Examples of critical
medical devices include but are not limited to needles, syringes, scalpels and
invasive/surgical instruments, all implantable devices, biopsy forceps and all
instruments used for foot care.16

Disinfection: A process involving killing a percentage of germs.1
Droplet precautions: These are additional to standard precautions and are designed to
reduce the transmission of infectious spread by the droplet route. The precautions
consist of a water resistant surgical or procedure mask and eye protection or face shield
for the health care worker.5, 15
Fit-tested mask: Is a mask that was fit via a process of selecting the correct size and
type of respirator (mask) and ensuring that the wearer knows how to use it correctly
(e.g., N95 mask).2
Fungus: Diverse group of organisms that thrive or grow in wet or damp areas and can
cause disease.1
Hand hygiene: A process for the removal of soil and transient microorganisms from the
hands. Hand hygiene may be accomplished using soap and running water or the use of
alcohol-based hand rubs. Optimal strength of alcohol-based hand rubs should be 60%
to 90% alcohol. Refer to the World Health Organization (2009) document entitled WHO
H
Guidelines on Hand Health Hygiene in Health Care .12 H
Health care associated infection: Also known as nosocomial infection and hospital-
associated infection. An infection acquired in hospital by a patient who was admitted for
a reason other than that infection. An infection occurring in a patient in a health care
facility in whom the infection was not present or incubating at the time of admission.
This includes infections acquired in the hospital but appearing after discharge, and also
occupational infection among staff of the facility.6
Hierarchy of control measures: A framework that includes three levels of control:

engineering controls, administrative controls and personal protective measures.
1. Engineering controls are built into the design (private bathrooms, private rooms,
HVAC systems) of a health care facility. Infection prevention and control
professionals should be involved in the design and planning of new facilities. An
infection control risk assessment should be done to evaluate and mitigate potential
risks for microorganism transmission by means of air, water and environmental
sources.
2. Administrative controls include protocols for hand hygiene, immunization of residents
and caregivers, protocols for managing caregivers and clients during an outbreak
and protocols for caring for clients with communicable diseases.
3. Personal protective equipment is the least desirable way to control hazards as it
does not eliminate them, it merely contains the hazard and is dependent on its
appropriate use by educated, knowledgeable staff.2
(Adapted from BC Centre for Disease Control Document on Respiratory Outbreaks)
High level disinfection (HLD): The level of disinfection required when processing
semi-critical medical equipment/devices. High level disinfection processes destroy

vegetative bacteria, mycobacteria, fungi and enveloped (lipid) and non-enveloped (non-
lipid) viruses, but not necessarily bacterial spores. Medical equipment/devices must be
thoroughly cleaned prior to high level disinfection.6, 12
Infection prevention and control (IPC): Evidence-based practices and procedures

that, when applied consistently in health care facilities and settings, can prevent or
reduce the risk of transmission of microorganisms to health care personnel, clients and
visitors.1, 16
Low level disinfection (LLD): The level of disinfection required when cleaning and
disinfecting non-critical equipment and environmental surfaces. Low level disinfection
does not kill mycobacteria, or bacterial spores, but will kill most vegetative bacteria and
some fungi.15, 16
Microorganism: Any organisms (animal or plant) of microscopic size.1
Non-critical equipment: Medical device that touches only intact skin (but not mucous
membranes) or does not directly touch the client. Intact skin acts an effective barrier
against most microorganisms; therefore, the sterility of items coming in contact with skin
is “non-critical”.16
Parasite: Organisms that grow, feed, and are sheltered on or in a different organism
while contributing nothing to the survival of the host.2
Personal protective equipment (PPE): Specialized equipment or clothing used by

health care workers to protect themselves from direct exposure to clients’ blood, tissue
or body fluids. Personal protective equipment may include gloves, gowns, fluid-resistant
aprons, head and foot coverings, face shields or masks, eye protection, and ventilation
devices (e.g., mouthpieces, pocket masks). It is the responsibility of the health care
worker to put on the appropriate personal protective equipment in any situation that is
likely to lead to exposure of blood, body fluids, excretions and secretions.15,16
Routine practices: Is the term used by Health Canada/Public Health Agency of

Canada to describe the system of infection prevention and control practices
recommended in Canada to prevent and control transmission of microorganisms in
health care settings. Consistent use of routine practices with all clients/
residents/patients is critical to preventing transmission of microorganisms from client to
client and client to staff. The full description of routine practices to prevent and control
transmission of nosocomial pathogens can be found on the Public Health Agency of
Canada website: http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/99vol25/25s4/index.html.5,16 PIDAC’s Routine Practices fact sheet is available at:
http://www.health.gov.on.ca/english/providers/program/infectious/pidac/fact_sheet/fs_ro
utine_010107.pdf.16

Semi-critical equipment: A medical device that comes in contact with mucous
membranes or non-intact skin, but does not penetrate them, including but not limited to
insert earphones, impedance probe tips, otoscope tips.15
Sharps: Objects capable of causing punctures or cuts (e.g., needles, syringes, blades,
glass).15,16
Single-usage: Refers to an item that may be used and reused on a single client, but
may not be reused on other clients.1
Spaulding classification: A strategy for reprocessing contaminated medical devices.

The system classifies medical devices as critical, semi-critical, or non-critical based
upon the risk from contamination on a device to client safety. The system also
establishes three levels of germicidal activity (sterilization, high-level disinfection, and
low-level disinfection) for strategies with the three classes of medical devices (critical,
semi-critical and non-critical).15
Standard precautions: Is the term used by the World Health Organization to describe
the system of infection prevention and control practices recommended to be applied to
all patients at all times regardless of their known or presumed infectious status. These
include: hand hygiene; risk assessment; risk reduction strategies; environmental
cleaning, disinfection, and sterilization; waste and laundry management; and healthy
workplace practices.4
Sterilization: The level of reprocessing required when processing critical medical

equipment/devices. The sterilization process results in the destruction of all forms of
microbial life including bacteria, viruses, spores and fungi.17
Vectorborne transmission: A manner of spreading disease whereby insects or

animals carrying a pathogenic agent transfer disease by interacting with a susceptible
host.1
Vehicle transmission: When disease is transmitted through ingestion of or exposure to

contaminated substances, via food, water, blood or bodily substances.9
Virus: Any of a large group of submicroscopic agents that act as parasites and consist
of a segment of DNA or RNA surrounded by a coat of protein. Because viruses are
unable to replicate without a host cell, they are not considered living organisms in
conventional taxonomic systems. Nonetheless, they are described as “live” when they
are capable of replicating and causing disease.8
Waste handling: All the activities, administrative and operational, involved in the
production, handling, treatment, conditioning, storage, transportation and disposal of
waste generated by health-care establishments. Waste is divided into three categories;
general (e.g., used gloves, tongue depressors), biomedical (e.g., sharps) and
pathological (body tissue or fluids).11

REFERENCES
10BU
1. Bankaitis, A.U., Kemp, R. (2005). Infection Control in the Audiology Clinic. 2nd
Ed. Chesterfield, MO: Aukse E. Bankaitis.
2. Canadian Committee on Antibiotic Resistance (June 2007). Infection prevention

and control best practices for long term care, home and community care
including health care offices and ambulatory clinics. Retrieved on April 3, 2009
from: http://www.ccar-ccra.com/english/pdfs/IPC-BestPractices-June2007.pdf
3. Clark, J.G., Kemp, R.J. and Bankaitis, A.U. (2003). Infection Control in
Audiological Practice. Audiology Today. Volume 15 (5): p. 12-19.
4, World Health Organization (2004). Practical guidelines for infection control in

health care facilities. Retrieved on April 14, 2009 from:
http://www.wpro.who.int/NR/rdonlyres/006EF250-6B11-42B4-BA17-
C98D413BE8B8/0/practical_guidelines_infection_control.pdf
5. Ontario Ministry of Health and Long Term Care (2004). Preventing respiratory
illnesses in community settings: Guidelines for infection control and surveillance
for febrile respiratory illness (FRI) in community settings in non-outbreak
conditions. Retrieved on May 29, 2009 from:
http://www.health.gov.on.ca/english/providers/program/pubhealth/sars/docs/docs
3/guide_fri_comm_031104.pdf
6. Ontario Ministry of Health and Long Term Care (2005). Infection prevention and
control core competencies education. Retrieved on May 29, 2009 from:
http://www.health.gov.on.ca/english/providers/program/infectious/infect_prevent/i
pccce_mn.html
7 CHICA (2006). Infection prevention and control core competencies for health
care workers: A consensus document. Retrieved on April 26, 2009 from:
http://www.chica.org/pdf/corecompfinal.pdf
8 Bankaitis, A.U., Kemp, R. (2003). Infection Control in the Hearing Aid Clinic.
Chesterfield, MO: Aukse E. Bankaitis.
9. Frequently Asked Questions. Methods of Disease Transmission. Department of

Microbiology. Mount Sinai Hospital. Accessed on June 20, 2009 at
http://microbiology.mtsinai.on.ca/faq/transmission.shtml.
10. Guidelines for Infection Prevention and Control in the Physician’s Office. BC
Centre for Disease Control. 2004. Accessed on June 20, 2009 at
http://www.bccdc.ca/NR/rdonlyres/84DA413D-C943-4B5F-94F1-
794C5B76C9CE/0/InfectionControl_GF_IC_In_Physician_Office.pdf

11 Bankaitis, A.U. and Kemp, Robert J. (2003). Infection Control in the Hearing Aid
Clinic. Chesterfield, MO: Aukse E. Bankaitis.
12. World Health Organization (2009). WHO guidelines on hand hygiene in health
care. Retrieved on July 8, 2009 from:
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
13. Public Health Agency of Canada (2009). Interim guidance: Infection prevention
and control measures for prehospital care-Pandemic (H1N1) 2009 flu virus.
Retrieved on August 17, 2009 from: http://www.phac-aspc.gc.ca/alert-
alerte/h1n1/hp-ps/a1-eng.php
14. Occupational Health & Safety Agency for Healthcare in BC (OHSAH) (2008).
Home and community care risk assessment tool: Resource guide. Retrieved on
July 8, 2009 from: http://www.ohsah.bc.ca/media/161-HB-
Risk_Assessment_Tool.pdf
15, College of Audiologists and Speech Language Pathologists of Ontario (2006).

Infection control for regulated professionals. Retrieved on April 3, 2009 from:
http://www.caslpo.com/Portals/0/positionstatements/InfectionControlCASLPOEDI
TION.pdf
16. Provincial Infectious Diseases Advisory Committee (PIDAC), Ontario Ministry of

Health and Long Term Care (April 2008). Best practices for cleaning, disinfection
and sterilization in all health care settings. Retrieved on July 8, 2009 from:
http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_
prac/bp_cds_2.pdf
17. A Guide to Selection and Use of Disinfectants. 2003. BCCDC Laboratory Services.
Accessed on June 22, 2009 at http://www.bccdc.ca/NR/rdonlyres/EAA94ACF-
02A9-4CF0-BE47-
3F5817A25669/0/InfectionControl_GF_DisinfectntSelectnGuidelines_nov0503.pdf
18. Duke University and Medical Center. Animal Care and Use Program. Guidelines
for Sterilization and Disinfection. Accessed on June 22, 2009 at
http://vetmed.duhs.duke.edu/guidelines_for_sterilization_disinfection.htm.
19. Kemp, Robert J., Bankaitis, Aukse. Infection Control in Audiology. Audiology
Online. Accessed on June 22, 2009 at
http://www.audiologyonline.com/articles/article_detail.asp?article_id=214
20. Best Practice Guidelines for the Cleaning, Disinfection and Sterilization of
Medical Devices in Health Authorities, March 2007. B.C. Patient Safety Branch,
Ministry of Health

21. Fallis, P. (2004) Infection Prevention and Control in Office-Based Health Care
and Allied Services, 2nd Edition. Ontario: Canadian Standards Association.

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INFECTION PREVENTION AND

CONTROL GUIDELINES FOR

INTERORGANIZATIONAL GROUP FOR SPEECH-

Interorganizational Group for Speech-Language Pathology and Audiology

Update and Review

Changes to Web Links

PURPOSE AND SCOPE ................................................................................................ 2

GUIDING PRINCIPLES .................................................................................................. 3

THE SCIENCE OF INFECTION CONTROL ................................................................... 4

STANDARD PRECAUTIONS OR ROUTINE PRACTICES ............................................ 8

Infection Prevention and Control Guidelines for Audiology Page 1

PURPOSE AND SCOPE

This document reviews standard † or routine precautions and additional precautions

Infection Prevention and Control Guidelines for Audiology Page 2

Infection Prevention and Control Guidelines for Audiology Page 3

3BU THE SCIENCE OF INFECTION CONTROL

The Immune System

Knowing the methods in which a disease is transmitted is important for implementing

Infection Prevention and Control Guidelines for Audiology Page 4

Infection Prevention and Control Guidelines for Audiology Page 5

a. Direct Contact Transmission: type of contact transmission which requires

b. Indirect Contact Transmission: refers to situations where a susceptible person

c. Droplet Contact Transmission: diseases can be transferred by infected

2. Vehicle Transmission: occurs when disease is spread through ingestion of or

3. Airborne Transmission: refers to situations where residue from evaporated

Infection Prevention and Control Guidelines for Audiology Page 6

4. Vectorborne Transmission: vectors are animals or insects that carry disease

Standard Precautions or Routine Practices

As mentioned previously, standard or routine precautions are to be applied to all clients

The elements classified as standard precautions/routine practices include:

The Canadian Committee on Antibiotic Resistance (CCAR)2 (http://www.ccar-

Infection Prevention and Control Guidelines for Audiology Page 7

5BU STANDARD PRECAUTIONS OR ROUTINE PRACTICES

Audiologists should perform hand hygiene:

Alcohol-based hand rubs are recommended to decontaminate hands in clinical

Infection Prevention and Control Guidelines for Audiology Page 8

Hand Washing Technique:

Risk assessment* is the process of systematically evaluating risks to safety and

Step one: Identifying hazards and those at risk:

Step two: Evaluating and prioritizing risks:

Step three: Deciding on preventive action to eliminate or control the risks

Infection Prevention and Control Guidelines for Audiology Page 9

Information regarding when to stay at home or cancel an appointment should be

Risk Reduction Strategies

Infection Prevention and Control Guidelines for Audiology Page 10

Respiratory etiquette* involves measures to contain respiratory secretions for all

Patients should be prompted to self-assess when booking appointments and should be

A sample respiratory etiquette poster is available on page 31 of the The Canadian

Maintaining a 1 to 2 metre distance from a client is recommended until an initial

Personal Protective Equipment

Infection Prevention and Control Guidelines for Audiology Page 11

Remove or change gloves and perform hand hygiene when:

Gloves should be removed immediately after completion of the procedure at point of

Proper procedure for removal of gloves is as follows:

Infection Prevention and Control Guidelines for Audiology Page 12

Gowns are recommended to be worn anytime the chance of contamination to clothing

The proper sequence for donning PPE is as follows:

The proper sequence for removal of PPE is as follows:

Refer to page 37 of The Canadian Committee on Antibiotic Resistance (CCAR) (2007)2

Infection Prevention and Control Guidelines for Audiology Page 13

Infection Prevention and Control Guidelines for Audiology Page 14

1.1 Levels of Reprocessing:

Disinfection: refers to the inactivation of disease-producing microorganisms17 and